Clinical suspicion, diagnosis and management of cardiac amyloidosis: update document and executive summary.

In recent years, the interest in cardiac amyloidosis has grown exponentially. However, there is a need to improve our understanding of amyloidosis in order to optimise early detection systems. Therefore, it is crucial to incorporate solutions to improve the suspicion, diagnosis and follow-up of cardiac amyloidosis. In this sense, we designed a tool following the different phases to reach the diagnosis of cardiac amyloidosis, as well as an optimal follow-up: a) clinical suspicion, where the importance of the "red flags" to suspect it and activate the diagnostic process is highlighted; 2) diagnosis, where the diagnostic algorithm is mainly outlined; and 3) follow-up of confirmed patients. This is a practical resource that will be of great use to all professionals caring for patients with suspected or confirmed cardiac amyloidosis, to improve its early detection, as well as to optimise its accurate diagnosis and optimal follow-up.

VAP risk index: Early prediction and hospital phenotyping of ventilator-associated pneumonia using machine learning.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in intensive care units (ICUs). Early identification of patients at risk of VAP enables early intervention, which in turn improves patient outcomes. We developed a predictive model for individualized risk assessment utilizing machine learning to identify patients at risk of developing VAP. METHODS: The Philips eRI dataset, a multi-institution electronic medical record (EMR), was used for model development. For adult (≥18y) patients, we propose a set of criteria using indications of the start of a new antibiotic treatment temporally contiguous to a microbiological test to mark suspected infection events, of which those with a positive culture are labeled as presumed VAP if 1) the event occurs at least 48 h after intubation, and 2) there are no indications of community-acquired pneumonia (CAP) or other hospital-acquired infections (HAI) in the patient charts. The resulting VAP and no-VAP (control) cases were then used to build an ensemble of decision trees to predict the risk of VAP in the next 24 h using data on patients' demographics, vitals, labs, and ventilator settings. RESULTS: The resulting model predicts the development of VAP 24 h in advance with an AUC of 76 % and AUPRC of 75 %. Additionally, we group hospitals that are similar in healthcare processes into distinct clusters and characterize VAP prediction for the identified hospital clusters. We show inter-hospital (teaching status and healthcare processes) and cohort-specific (age groups, gender, early vs late VAP, ICU mortality status) differences in VAP prediction and associated symptomologies. CONCLUSIONS: Our proposed VAP criteria use clinical actions to mark incidences of presumed VAP infection, which enables the development of models for early detection of these events. We curated a patient cohort using these criteria and used it to build a model for predicting impending VAP events prior to clinical suspicions. We present a clustering approach for tailoring the VAP prediction model for different hospital types based on their EMR data characteristics. The model provides an instantaneous risk score that allows early interventions and confirmatory diagnostic actions.

Isolated Fallopian Tube Torsion: Diagnosis and Management of a Gynecologic Emergency.

Isolated fallopian tube torsion (IFTT) is a rare gynecologic emergency that requires a high index of suspicion and immediate surgical intervention. IFTT is rarely diagnosed preoperatively due to the lack of pathognomonic signs and symptoms. A 15-year-old female with no medical history presented with acute lower abdominal pain, nausea, and a physical exam significant for diffuse abdominal tenderness to palpation. Ultrasound revealed a large cystic adnexal mass with patent vascular flow to the ipsilateral ovary. Vital signs were stable and laboratory evaluation was unremarkable. Due to an uncertain diagnosis and suspicion of incomplete ovarian torsion, a laparoscopy was performed, which revealed an IFTT and ipsilateral hemorrhagic ovarian cyst. Treatment consisted of unilateral salpingectomy with cystectomy. IFTT is a surgical emergency with nonspecific signs and symptoms. A high degree of clinical suspicion is needed for prompt management. Diagnostic laparoscopy can be a useful tool in the setting of an uncertain diagnosis.

Case Report: Novel Pathogenic Variant Detected in Two Siblings with Type 1 Gaucher Disease.

BACKGROUND: Gaucher disease (GD) is an autosomal recessive lysosomal storage disease. The disease develops due to glucocerebrosidase enzyme deficiency caused by biallelic pathogenic variants in the glucosylceramidase beta 1 (GBA1) gene, which encodes the glucocerebrosidase enzyme. The GBA1 gene is located at chromosomal location 1q22 and consists of 11 exons. In this article, we report a novel pathogenic variant in the GBA1 gene. CASE PRESENTATIONS: A 32-year-old female patient with no known chronic disease was admitted with complaints of weakness, bone pain, and abdominal pain. Her evaluation included hepatosplenomegaly, thrombocytopenia, osteoporosis, and anemia. The clinical suspicion of Gaucher disease was confirmed by glucocerebrosidase enzyme level and genetic testing. In her family screening, her sister also had hepato-splenomegaly, osteoporosis, thrombocytopenia, and anemia. Both sisters had no neurological symptoms. As a result of GBA1 gene sequence analysis in two of our patients, a missense variant was detected in the c.593C>A homozygous genotype. This variant has not been reported in any previously published case. CONCLUSION: In this case report, we aimed to contribute to the literature by reporting a new novel pathogenic variant in the GBA1 gene leading to type 1 Gaucher disease that has not been described before.

Inconsistent Provider Testing Practices for Congenital Cytomegalovirus: Missed Diagnoses and Missed Opportunities.

Newborn congenital cytomegalovirus (cCMV) screening programs have been found to increase the rates of early diagnosis and treatment. In North America, newborn cCMV screening programs have not been widely implemented, leaving healthcare providers to rely on clinical suspicion alone to prompt testing. This study sought to examine healthcare providers' cCMV testing practices at a quaternary children's hospital. A retrospective review of the electronic health record was completed for eligible infants over a six-year period. Bivariate calculations and analyses were performed. Between 2014 and 2019, a total of 40,091 infants were cared for at the study institution, of which 178 were tested for cCMV and 10 infants were diagnosed with cCMV. Isolated small-for-gestational age was the most common indication (53/178) to prompt testing. Overall, the cCMV testing rate was 4.5 tests per 1000 infants, with a resulting diagnostic prevalence of 0.2 cases per 1000 infants, which is 15-fold lower than the expected prevalence. Providers relying on clinical suspicion alone are infrequently testing infants for cCMV, resulting in missed diagnoses and missed opportunities for treatment. Systematic cCMV screening practices may improve diagnosis, treatment, and childhood outcomes.

Widening spectrum of neuroleptic malignant syndrome: Case series.

Neuroleptic malignant syndrome (NMS) is a rare and rapidly progressive syndrome with mortality rate of 5.6%. The spectrum of onset, progression and outcome is heterogeneous and is associated with number of risk factors. In our case series, we entail the triggers, hospital course and outcome of five interesting in-patient cases that were admitted to our service in a tertiary care hospital in Northern India. This case series is to highlight the first ever reported case of NMS triggered by levosulpiride administration, along with one of the few first cases of NMS after programming of DBS, hypothyroid disorders, levodopa readjustment and selective basal ganglia and cerebellar injury following the hyperthermic syndrome. This is also to bring to attention of clinicians worldwide the atypical risk factors of NMS, and stress the importance of staying vigilant for the same by frequent follow-ups and high degree of clinical suspicion. We also aim to generate epidemiological data about these atypical triggers.

Epidemiological study of granulomatous prostatitis in a tertiary hospital: Associated risk factors and relationship with prostate cancer.

OBJECTIVE: The primary objective was to estimate the incidence of granulomatous prostatitis (GP) in Son Espases University Hospital, a tertiary care hospital, in Palma de Mallorca (Spain). As secondary objectives, presence of concomitant PCa in the biopsy was analyzed, as well as the history of previous BCG instillations, biopsy origin, urinary symptoms, and cardiovascular risk (CV) factors. METHODS: A descriptive retrospective study of GP and the aforedescribed variables were carried out from 2010 to 2017. RESULTS: A total of 3651 histopathological prostate specimens were analyzed, 39 of which were diagnosed with GP (incidence of 1.06%). Lower urinary tract symptoms (LUTS) were present in a 48.7% and previous history of bladder tumor resection (TURBT) was present in 35.9% of the cases. Also, urinary tract infections were equally present. All cases with prior TURBT had intravesical instillations with BCG, although 5 (12.8%) and 4 (10.3%) cases had abnormal rectal examination and elevated PSA levels after instillations, respectively. Finally, in 14 cases (35.9%) there was also a diagnosis of concomitant PCa. The most common CV risk factor in these patients was smoking (79.5%) followed by hypertension (64.8%). CONCLUSIONS: The estimated incidence of GP in our center (1.06%)g is close to that described by other authors. About 14 cases were diagnosed with PCa (35.9%), a higher value than previously described in the literature, and most of these were found incidentally, especially in cystoprostatectomies. This high percentage of concomitant GP and PCa could be due to a rise in Transrectal Prostate biopsies (TRPB), as in recent years there has been a tendency to increase the use of PSA in routine clinical practice.

"The Great Masquerader": An Interesting Case Series of Pulmonary Thromboembolism.

Venous thromboembolism (VTE) encompasses pulmonary embolism (PE) and deep vein thrombosis (DVT). The clinical manifestations of pulmonary embolism are highly variable and non-specific. We report five cases of pulmonary embolism, each with a unique clinical profile and degree of severity. The clinical, electrocardiographic, and radiologic findings of each patient are described in this case series along with the appropriate therapy based on hemodynamic stability. It is crucial to distinguish between hemodynamically stable and unstable pulmonary embolism and treatment should be started right away to reduce morbidity and mortality secondary to obstructive shock.

Practical recommendations for the diagnosis and management of transthyretin cardiac amyloidosis.

Cardiac amyloidosis (CA) is an infiltrative restrictive cardiomyopathy caused by accumulation in the heart interstitium of amyloid fibrils formed by misfolded proteins. Most common CA types are light chain amyloidosis (AL) caused by monoclonal immunoglobulin light chains and transthyretin amyloidosis (ATTR) caused by either mutated or wild-type transthyretin aggregates. Previously considered a rare disease, CA is increasingly recognized among patients who may be misdiagnosed as undifferentiated heart failure with preserved ejection fraction (HFPEF), paradoxical low-flow/low-gradient aortic stenosis, or otherwise unexplained left ventricular hypertrophy. Progress in diagnosis has been due to the refinement of cardiac echocardiographic techniques (speckle tracking imaging) and magnetic resonance (T1 mapping) and mostly due to the advent of bone scintigraphy that has enabled noninvasive diagnosis of ATTR, limiting the need for endomyocardial biopsy. Importantly, proper management of CA starts from early recognition of suspected cases among high prevalence populations, followed by advanced diagnostic evaluation to confirm diagnosis and typing, preferentially in experienced amyloidosis centers. Differentiating ATTR from other types of amyloidosis, especially AL, is critical. Emerging targeted ATTR therapies offer the potential to improve outcomes of these patients previously treated only palliatively.

Impact of Rapid Influenza Molecular Testing on Management in Pediatric Acute Care Settings.

OBJECTIVES: To measure the impact of rapid influenza real-time qualitative reverse transcriptase polymerase chain reaction (RT-PCR) on patient management in busy pediatric emergency department (ED) and urgent care clinic settings. STUDY DESIGN: We developed a brief, elective survey that clinicians completed when an influenza RT-PCR order was placed in the ED or urgent care clinic between February 18, 2019, and March 13, 2019. We captured the clinical suspicion for influenza, intended management plans, and actual management plans once influenza RT-PCR results were available. RESULTS: We evaluated 339 encounters, of which 164 (48.4%) had a positive influenza RT-PCR. Clinical suspicion for influenza was a nonsignificant predictor for influenza PT-PCR positivity (P = .126). After rapid influenza RT-PCR results were available, clinicians changed their original plans in 44.5% of influenza RT-PCR positive vs 92.6% of influenza RT-PCR negative cases (P < .0001). Change in plans for antiviral use was observed in 26% of influenza positive vs 77% of influenza negative cases (P < .0001). A total of 135 antiviral prescriptions were avoided in patients with negative influenza RT-PCR. CONCLUSIONS: Implementation of a rapid and accurate influenza RT-PCR in the acute care setting is important to systematically diagnose influenza in children and improve outpatient management decisions, because clinical suspicion for influenza is inaccurate. A negative influenza RT-PCR decreases unnecessary antiviral use and has the potential for significant cost savings.

[Analysis of the degree of clinical suspect in patients with congenital adrenal hyperplasia by 21-hydroxylase deficiency before obtaining the result of the newborn screening program of the autonomous Community of Madrid.] / Análisis del grado de sospecha clínica en pacientes con hiperplasia suprarrenal congénita por déficit de 21 hidroxilasa antes de la obtención del resultado del cribado neonatal en la Comunidad de Madrid.

OBJECTIVE: The objective of this study was to analyze the clinical suspicion and where the patients were when they received the result of the neonatal screening for 21 hydroxylase deficiency (21OHD). METHODS: The present data were derived from a retrospective analysis of a group of patients with classical 21OHD discovered by newborn screening and treated at the Center for Clinical Follow-up of the Autonomous Community of Madrid. Stadistic analysis of the data was performed using version 15.5 of the SPSS® software. RESULTS: During the period from 1990 to 2015 of this study 46 children were diagnosed with classical 21OHD [36 with the salt-wasting (SW) and 10 with simple virilizing form (SV)]. The median age at diagnosis for the patients with the SW and SV form were 8.0 (6.0-9.0) and 18.0 (14.5-37.5) days respectively (P=0.001). In 35 (76.1%) patients the disease had not been suspected before the result of newborn screening, 28 patients affected by SW form, with a potential risk of death due to adrenal crisis (of which, in addition 6 women with incorrect assignment of sex at birth) and 7 patients affected with SV form. Two thirds of the patients with classic forms identified by neonatal screening were in their homes without suspicion of any disease or pending any additional study. CONCLUSIONS: Neonatal screening provided better performance than clinical suspicion. In the majority of patients with 21OHD detected by newborn screening, the diagnosis by screening was anticipated to the clinical suspicion of the disease even in female patients with ambiguous genitalia.

OBJETIVO: El objetivo de este estudio fue analizar el grado de sospecha clínica y donde estaban los pacientes cuando recibieron el resultado del cribado neonatal por déficit de 21 hidroxilasa (21OHD). METODOS: Los datos presentados fueron extraídos del análisis retrospectivo de pacientes diagnosticados de formas clásicas de 21OHD mediante Programa de Cribado Neonatal y atendidos en el Centro de Seguimiento Clínico de la Comunidad Autónoma de Madrid. El análisis estadístico de los datos se realizó empleando la versión 15.5 del software SPSS®. RESULTADOS: Durante el período comprendido entre 1990 a 2015, 46 niños fueron diagnosticados de formas clásicas por 21OHD [36 con pérdida salina (PS) y 10 con forma virilizante simple (VS)]. La edad mediana al diagnóstico de los pacientes con forma PS y forma VS fue 8,0 (6,0-9,0) y 18,0 (14,5-37,5) días respectivamente (P=0,001). En 35 (76,1%) pacientes la enfermedad no había sido sospechada antes del resultado del cribado neonatal, 28 pacientes estaban afectados de forma PS, con potencial riesgo de muerte debido a crisis adrenal (de ellos, 6 eran además mujeres en las que se había realizado una asignación incorrecta de sexo al nacimiento) y 7 pacientes afectados de forma VS. Dos tercios de los pacientes con formas clásicas identificados por cribado neonatal estaban en sus domicilios sin sospecha de ninguna enfermedad ni pendientes de completar estudios. CONCLUSIONES: El cribado neonatal proporciona mejor rendimiento que la sospecha clínica. En la mayoría de pacientes con 21OHD detectados por cribado neonatal, el diagnostico por cribado fue previo a la sospecha clínica de la enfermedad incluso en pacientes mujeres con ambigüedad genital.

Características clínicas y para clínicas de los pacientes con fiebre manchada por Ricketts ia ricketts ii en Panamá (1950­-1951; 2004­-2017) / Clinical and para clinical characteristics of patients with fevers potted by Rickettsiarickettsii in Panama (1950­1951; 2004­2017)

La fiebre manchada causada por Ric ketts ia ric ketts iies por mucho la enfermedad transmitida por garrapatas más importante en América Latina y una de las zoonosis más relevante del continente. En Panamá esto es notorio si se considera que los casos confirmados de la misma se han registra­ do en dos series: 1950­1951, donde se presentaron cinco casos, donde los dos primeros fueron re­ sultaron fatales, y de 2004­2017, donde se confirmaron 10 casos, con nueve fallecimientos. A pes ar de lo anterior, la fiebre manchada causada por Rrickettsii es una enfermedad de baja preva­lencia y está dentro de las enfermedades desatendidas. El diagnóstico oportuno de Rrickettsii en personas afectadas por la misma, incrementa la posibilidad de sobrevivencia del paciente; sin em­bargo, a pesar de su alto porcentaje de mortalidad, esta enfermedad es poco reconocida y no se cuenta con sospecha clínica. Con el objetivo de presentar sus características clínicas en Panamá, se analizan individualmente cada reportes de caso, incluyendo datos etarios , de localidad, sínto­mas descritos, análisis aplicados y tratamiento.

The spotted fever caused by Ric ketts ia rickettsii is by far the most important tick­borne disease in Latin America and one of the most important zoonoses in the continent. In Panama this is notorious if it is considers that the confirmed cases have been registered in two series: 1950­1951, with five cas es and two fatal; and 2004­2017, with 10 cases and nine deaths. Despite the above, spotted fe­ver caused by R. rickettsii is a disease of low prevalence and is among the neglected diseases. The timely diagnosis of Rrickettsii in people affected by it, increases the possibility of survival of the pa­tient; however, despite its high mortality rate, this disease is poorly recognized and there is no clini­ cal suspicion. In order to present their clinical characteristics in Panama, each reports of case is analyzed individually, including age, location, symptoms described, applied analysis and treatmen

Interstitial pneumonia with autoimmune features (IPAF) and radiological findings suggestive of lymphocytic interstitial pneumonia (LIP) - case report.

Interstitial pneumonia with autoimmune features (IPAF) is a term to describe individuals with both interstitial lung disease (ILD) and combinations of other clinical, serologic, and/or pulmonary morphologic features, which presumably originate from an underlying systemic autoimmune condition, but do not meet current rheumatologic criteria for a defined connective tissue disease (CTD). Predominantly, interstitial pneumonia arises in the course of an established CTD, but it is not so rare for the ILD to be the first, and possibly the one and only manifestation of a latent CTD. Lymphocytic Interstitial Pneumonia (LIP) is an uncommon disease, characterized by infiltration of the interstitium and alveolar spaces of the lung by lymphocytes, plasma cells and other lymphoreticular elements. The cause of LIP is still unknown but it could be also a manifestation of CTD. Clinically, it is highly variable, from spontaneous resolution to progressive respiratory failure and death despite glucocorticoid treatment. Since there are no recent standards for the management of LIP, the disease is treated empirically. We report a case of a HIV-negative 54-year-old woman, who was suspected of LIP according to clinical features and radiological findings. Positive laboratory results were highly suggestive of underlying autoimmune process, but did not fulfil the criteria of any particular CTD. Because of severe general condition of the patient, immunosuppressive treatment was started immediately, without further invasive diagnostics including lung biopsy, which is required for a definitive diagnosis. We present two-year observation of the patient with all our doubts concerning clinical proceedings.

Clinical recognition of acute aortic dissections: insights from a large single-centre cohort study.

AIMS: Acute aortic dissection (AD) requires immediate treatment, but is a diagnostic challenge. We studied how often AD was missed initially, which patients were more likely to be missed and how this influenced patient management and outcomes. METHODS: A retrospective cohort study including 200 consecutive patients with AD as the final diagnosis, admitted to a tertiary hospital between 1998 and 2008. The first differential diagnosis was identified and patients with and without AD included were compared. Characteristics associated with a lower level of suspicion were identified using multivariable logistic regression, and Cox regression was used for survival analyses. Missing data were imputed. RESULTS: Mean age was 63 years, 39% were female and 76% had Stanford type A dissection. In 69% of patients, AD was included in the first differential diagnosis; this was less likely in women (adjusted relative risk [aRR]: 0.66, 95% CI: 0.44-0.99), in the absence of back pain (aRR: 0.51, 95% CI: 0.30-0.84), and in patients with extracardiac atherosclerosis (aRR: 0.64, 95% CI: 0.43-0.96). Absence of AD in the differential diagnosis was associated with the use of more imaging tests (1.8 vs. 2.3, p = 0.01) and increased time from admission to surgery (1.8 vs. 10.1 h, p < 0.01), but not with a difference in the adjusted long-term all-cause mortality (hazard ratio: 0.76, 95% CI: 0.46-1.27). CONCLUSION: Acute aortic dissection was initially not suspected in almost one-third of patients, this was more likely in women, in the absence of back pain and in patients with extracardiac atherosclerosis. Although the number of imaging tests was higher and time to surgery longer, patient outcomes were similar in both groups.

Crohn's disease confined to the duodenum: A case report.

Crohn's disease (CD) can involve any part of the gastrointestinal tract from the mouth to anus. However, gastroduodenal CD is rare with a frequency reported to range between 0.5% and 4.0%. Most patients with gastroduodenal CD have concomitant lesions in the terminal ileum or colon, but isolated gastroduodenal Crohn's disease is an extremely rare presentation of the disease accounting for less than 0.07% of all patients with CD. The symptoms of gastroduodenal CD include epigastric pain, dyspepsia, early satiety, anorexia, nausea, vomiting, and weight loss. The diagnosis of gastroduodenal CD requires a high level of clinical suspicion and can be made by comprehensive clinical evaluation. Here we report a rare case of isolated duodenal CD not confirmed by identification of granuloma on biopsy, but diagnosed by clinical evaluation.

Early diagnosis and treatment in a child with foodborne botulism.

INTRODUCTION: Foodborne botulism is a neuroparalytic disease caused by ingestion of food contaminated with botulinum toxins. Despite rare the mortality rate is high if untreated. Diagnosis of botulism is still a challenge for clinician, due to the variability of clinical manifestations and disease course. We report on a child with type B botulin intoxication who was early diagnosed and treated underlining that clinical suspicion is crucial to start prompt treatment. CASE PRESENTATION: An 11-year-old boy presented with bilateral ptosis and mydriasis, dry mouth, difficulty in swallowing, dysphonia, urine retention and constipation. Clear sensorium and no fever were observed. Immediately the suspicion of botulism was risen and botulinum antitoxin was administered. 3 days later serum and rectal samples tested positive for Clostridium botulinum. The patient completely recovered when discharged from hospital. DISCUSSION: Foodborne botulism is still possible in developed countries. The confirmation test of botulism requires some days. To avoid long delays between intoxication and diagnosis prompt clinical suspicion is thus crucial. The outcome depends on rapid implementation of appropriate management with intensive respiratory care and antitoxin administration.

¹8F-FDG PET/CT and Colorectal Cancer: Value of Fourth and Subsequent Posttherapy Follow-up Scans for Patient Management.

UNLABELLED: The purpose of this study was to evaluate the added value of a fourth and subsequent follow-up PET/CT scans to clinical assessment and impact on patient management in patients with colorectal cancer. METHODS: This was an institutional review board-approved, retrospective study. Eight hundred twenty-two patients with biopsy-proven colorectal cancer, who underwent (18)F-FDG PET/CT, were identified from 2000 to 2012. Among these, 73 (8.9%) patients underwent 4 or more follow-up PET/CT scans, with a total of 313 fourth and subsequent follow-up PET/CT scans. Median follow-up from the fourth follow-up PET/CT scan was 41.7 mo. The added value of each follow-up PET/CT scan, for clinical assessment and the treatment changes subsequent to each follow-up PET/CT scan, was established. Overall survival prediction was established using Kaplan-Meier plots with a Mantel-Cox log-rank test. RESULTS: Of the 313 fourth and subsequent follow-up PET/CT scans, 174 (55.6%) were interpreted as positive and 139 (44.4%) were interpreted as negative for recurrence or metastases. Thirty-four (46.6%) patients died during the study period. PET/CT identified recurrence or metastasis in 40.0% of scans obtained without prior clinical suspicion and ruled out disease in 23.6% of scans obtained with prior clinical suspicion. The PET/CT scan resulted in treatment change after 34.2% (107/313) of the scans. New treatment was initiated after 24.0% (75/313) of the scans, and treatment was changed after 8.0% (25/313) scans. There was a statistically significant difference in the overall survival between patients with a positive and all negative fourth and subsequent follow-up PET/CT scans at the patient level (log-rank, P = 0.001). CONCLUSION: The fourth and subsequent (18)F-FDG PET/CT scans obtained after primary treatment completion add value to clinical assessment and the management plan and provide prognostic information in patients with colorectal cancer.

18F-FDG PET/CT and lung cancer: value of fourth and subsequent posttherapy follow-up scans for patient management.

UNLABELLED: The Centers for Medicare and Medicaid Services recently ruled that only 3 posttherapy follow-up (18)F-FDG PET/CT scans are funded for a tumor type per patient and any additional follow-up PET/CT scans will be funded at the discretion of the local Medicare administrator. The purpose of this study was to evaluate the added value of 4 or more follow-up PET/CT scans to clinical assessment and impact on patient management. METHODS: This was an institutional review board-approved, retrospective study. A total of 1,171 patients with biopsy-proven lung cancer who had undergone (18)F-FDG PET/CT at a single tertiary center from 2001 to 2013 were identified. Among these, 85 patients (7.3%) had undergone 4 or more follow-up PET/CT scans, for a total of 285 fourth and subsequent follow-up PET/CT scans. Median follow-up from the fourth follow-up PET/CT scan was 31.4 mo (range, 0-155.2 mo). The follow-up PET/CT scan results were correlated with clinical assessment and treatment changes. RESULTS: Of the 285 fourth and subsequent follow-up PET/CT scans, 149 (52.28%) were interpreted as positive and 136 (47.7%) as negative for recurrence or metastasis. A total of 47 patients (55.3%) died during the study period. PET/CT identified recurrence or metastasis in 44.3% of scans performed without prior clinical suspicion and ruled out recurrence or metastasis in 24.2% of scans performed with prior clinical suspicion. The PET/CT scan resulted in a treatment change in 28.1% (80/285) of the patients. New treatment was initiated for 20.4% (58/285) of the scans, treatment was changed in 5.6% (16/285), and ongoing treatment was stopped in 2.1% (6/285). CONCLUSION: The fourth and subsequent (18)F-FDG PET/CT scans performed during follow-up after completion of primary treatment added value to clinical assessment and changed management 28.1% of the time.